Become a Community Activist at Elder Care Online. We're looking
for individuals with backgrounds in any of the various disciplines related to elder care
giving -- legal & financial, Alzheimer's care, home health care, psychology and
spirituality, insurance plans, nursing homes and others. You can be a doctor, lawyer,
nurse or caregiver -- If you're interested in helping community members solve their elder
care problems, we'd like to hear from you.

Community activists will help monitor and moderate community
discussion forums, select guest speakers, choose topics for the newsletter and develop
special programming for the Elder Care Channel, Elder Care Online's Internet
broadcast station. Professionals who are already working in the elder care marketplace are
encouraged to apply. Please fill out the following form and we'll get back to you.

Name:

Title:

Street Address:

E-Mail Address:

How did you hear about ElderCare Online?:

What is your area of medical expertise (if any)?:

or Other:

What types of facilities have you worked in or do you work in? (please check all that
apply):

or Other:

What types of services or counseling have you provided or do you provide? (check all
that apply):

or Other:

Is there anything we missed? Please do not send a resume, list of degrees or
qualifications at this time.